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Lateral Condyle Fracture (Peds)

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Other Names

  • Lateral Epicondyle Fracture
  • Lateral Humeral Condyle Fracture

Background

  • Refer to fracture of the lateral condyle of the Humerus in pediatric patients
  • Prognosis is worse than other pediatric elbow fractures due to high risk of malunion, nonunion and often missed diagnosis

Epidemiology

  • Second most common elbow fracture in children[1]
  • 12-20% of pediatric elbow fractures
  • Average age is 6[2]

Pathophysiology

  • Etiology most often involves FOOSH injury
  • Pull off theory: avulsion of lateral condyle from common extensor muscles/ tendon[3]
  • Push off theory: Fall causes impaction of radial head into lateral condyle, pushing off lateral condyle[4]
  • Most likely a combination of both mechanisms[5]
  • Most commonly presents as aSalter Harris IV fracture pattern

Ossification Centers of the Elbow

Ossification center Age of Appearance on Xray Age of fusion
Capitellum 1 12
Radial Head 3 15
Medial Epicondyle 5 17
Trochlea 7 12
Olecranon 9 15
Lateral Epicondyle 11 12

Associated Injuries


Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • General: Physical Exam Elbow
  • History
    • Describe trauma, typically fall on outstretched hand
    • Reports lateral elbow pain, swelling, bruising
  • Physical
    • Unlikely deformity unless concomitant dislocation
    • Tenderness, bruising, swelling of lateral condyle
    • Ecchymosis implies unstable fracture (tear of aponeurosis of brachioradialis)
    • Pain with elbow flexion/extension, especially supination, wrist flexion

Evaluation

  • Radiographs
    • 3 view radiographs standard
    • Compare to contralateral elbow if unclear
    • Internal Oblique: Fracture fragment best seen[6]
    • AP: May demonstrate small metaphyseal flake
  • Arthrogram
    • Useful for minimally displaced fractures
  • CT
    • Indicated only in uncertain cases
  • MRI
    • Assess integrity of cartilage
    • Hard to perform in young children, require sedation
  • Ultrasound
    • Useful to evaluate articular cartilage
    • Can be used reliably to distinguish intact articular cartilage from an interrupted cartilaginous joint surface[7]
    • Requires skilled sonographer

Classification

Milch Classification

  • Type 1: Fracture line is lateral to trochlear groove (less common, stable)
  • Type II: Fracture line extends medially into trochlear groove (more common, unstable)

Fracture Displacement Classification - Weiss

  • Type 1: <2 mm, indicating intact cartilaginous hinge
    • Account for up to 69% of fractures[8]
  • Type 2: >2 mm and <4 mm displacement, intact articular cartilage on arthrogram
  • Type 3: >4 mm, articular surface disrupted on arthrogram

Management

Nonoperative

  • Controversial, recommend making decision in consultation with orthopedic surgeon
  • Indications
    • Type I (nondisplaced or <2 mm displacement)
    • Medial cartilage must be intact (confirmed on MRI)
  • Immobilization: Long Arm Cast at 90°
    • Duration is controversial, 3-7 weeks [9]
  • Repeat radiographs weekly (cast must be removed)

Operative

  • Indications
    • 2+ mm displacement
  • Technique
    • Closed reduction, percutaneous pinning (CRPP)
    • ORIF
    • Supracondylar osteotomy

Return to Play

  • Variable, discretion of surgeon

Complications

  • Nonunion
  • Malunion
  • Avascular Necrosis
  • Stiffness/ loss of ROM
  • Delayed union
  • Varus/Valgus
  • Growth Arrest
  • Lateral overgrowth

See Also


References


  1. Landin LA: Fracture patterns in children: Analysis of 8,682 fractures with special reference to incidence, etiology and secular changes in a Swedish urban population 1950-1979. Acta Orthop Scand Suppl 1983;202:1-109
  2. Stimson L: A Practical Treatise on Fractures and Dislocations. Philadelphia, PA, Lea Brothers & Co, 1900
  3. Jakob R, Fowles JV, Rang M, Kassab MT: Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg Br 1975; 57(4):430-436
  4. Milch H: Fractures and fracture dislocations of the humeral condyles. J Trauma 1964;4:592-607
  5. McLearie M, Merson RD: Injuries to the lateral condyle epiphysis of the humerus in children. J Bone Joint Surg Br 1954; 36(1):84-89.
  6. Song KS, Kang CH, Min BW, Bae KC, Cho CH: Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. J Bone Joint Surg Am 2007;89(1):58-63
  7. Vocke-Hell AK, Schmid A: Sonographic differentiation of stable and unstable lateral condyle fractures of the humerus in children. J Pediatr Orthop B 2001; 10(2):138-141
  8. Rutherford A: Fractures of the lateral humeral condyle in children. J Bone Joint Surg Am 1985;67(6):851-856
  9. Badelon O, Bensahel H, Mazda K, Vie P: Lateral humeral condylar fractures in children: A report of 47 cases. J Pediatr Orthop 1988;8(1):31-34.
Created by:
John Kiel on 18 June 2019 01:16:38
Authors:
Last edited:
11 November 2020 14:37:02
Categories:
Trauma | Pediatrics | Elbow | Upper Extremity | Fractures | Acute